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The Oklahoma Toddler
Survey (TOTS) is a two-year
follow-back survey to
the Oklahoma Pregnancy
Risk Assessment Monitor-ing
System (PRAMS) survey.
TOTS, developed in 1994,
provides a glimpse into the
health of Oklahoma’s tod-dler
population. Key topics
include health insurance,
child care, safety, tobacco
exposure, breastfeeding and
nutrition, illness and activity
limitations, injury, family
structure, and maternal and
paternal demographics.
Mothers with live infants
who respond to the PRAMS
survey are sent a TOTS
survey the month their
children turn 2-years-old.
TOTS is a mixed-mode sur-veillance
system. Two mail
surveys are sent in an
effort to gain participation
followed by telephone
surveillance for non-respondents.
The response
rate for 2006-2009 data
was 73.8% (n=5,221). Data
were weighted to repre-sent
the 2-year-old’s birth
cohort for those years.
For more information
please contact TOTS at
the Oklahoma State De-partment
of Health
(OSDH) at 405-271-6761
or TOTS@health.ok.gov.
Breastfeeding is a health
behavior with immediate
and long-term health
benefits for both the
mother and her infant.1
Advantages include
nutritional, immunologic,
developmental, psychologi-cal,
social, economic, and
environmental benefits.2
Maternal health benefits
include decreased post-partum
bleeding, decreased
risk of ovarian and breast
cancers, and an earlier
return to pre-pregnancy
weight. Child health
benefits include reduced
risks for common childhood
illnesses such as diarrhea,
respiratory tract infec-tions,
otitis media, and
urinary tract infections.
Most importantly, clinical
studies indicate breastfeed-ing
is an effective component
in the prevention of
childhood obesity.
Breastfeeding duration has
an inverse relationship to
pediatric overweight.3 The
Centers for Disease Control
and Prevention (CDC) esti-mates
that for every month a
child is breastfed, his or her
risk for childhood overweight
decreases by 4%, reaching a
plateau by nine months. Re-search
shows a 30% de-crease
in the odds for being
overweight for a child
breastfed for at least eight
full months when com-pared
to a child who was
never breastfed.3 The
American Academy of
Pediatrics (AAP) recom-mends
exclusive breast-feeding
for at least six
months.2
The breastfeeding goals
set forth in Healthy
People 2020 are to have
at least 60.6% of infants
breastfed for at least six
months, and have 34.1% of
infants breastfed until 12
months of age.
TOTS data from 2006-
2009 indicate that among
Oklahoma 2-year-olds only
29.7% (95% Confidence
Breastfeeding Duration Among Native Americans
July 2011
Volume 4, Issue 1
TOTS Brief
The Oklahoma Toddler Survey
In Oklahoma:
· Almost 30% of infants
were breastfed for at
least six months.
Thirteen percent were
breastfed for at least
12 months and 3.9%
breastfed for 18
months or more.
· Among Native Ameri-can
toddlers, 15.3% (CI
10.9, 21.0) were
breastfed at least six
months, the lowest
percentage of all races
for toddlers breastfed
or given breast milk for
at least six months.
· For Native American
mothers, non-smokers
were twice as likely as
smokers to breastfeed
for six months or more
(45% vs. 23%).
· Maternal education was
the most significant
predictor of breast-feeding
duration at six
months among Native
American mothers.
An EEO Employer
What is TOTS?
Only 7.7% of Native American mothers breastfed their babies until 12
months of age, far less than the 34.1% goal for Healthy People 2020.
Interval (CI) 27.8–31.7) were breastfed
for at least six months; and 13.3% (95% CI
11.9-14.8) were breastfed at least 12
months. Overall, Native American toddlers
were shown to have the lowest duration
rate at six months (15.3%, 95% CI 10.9-
21.0) compared to white toddlers (31.2%,
95% CI 29.0-33.5).
Among Native Americans, maternal
education was the only significant predictor
of breastfeeding duration at six months
when controlling for select maternal
demographics, behaviors, and characteris-tics.
Native American mothers who had
attained at least a high school education
were 14 times more likely to breastfeed
for six months or more when compared to
Native American mothers with less than a
high school education (data not shown).
The OSDH Maternal and Child Health
Service and the Oklahoma City Area
Inter-Tribal Health Board Tribal
Breastfeeding Duration, cont.
Epidemiology Center are working
together to improve breastfeeding
initiation and duration rates in Oklahoma.
Six evidence-based interventions to pro-mote
breastfeeding are: Maternity care
practices; support for breastfeeding in
the workplace; peer support; educating
mothers; professional support; and media
and social marketing. The effectiveness
of professional education and public
acceptance has yet to be established.4
References:
1. Rhodes KL, et. Al., American Indian Breast-feeding
Attitudes and Practices in Minnesota,
Maternal and Child Health Journal , 2008 Vol.
12, Supp. 1, 46-54.
2. Policy Statement. Pediatrics, Vol. 115,
No. 2 Feb 2005, pp. 496-506.
3. Harder T, Bergmann R, Kallischnigg G, Plage-mann
A. Duration of breastfeeding and risk
of overweight: a meta-analysis. Am J Epide-miol
2005; 162:397-403.
4. Shealy KR, et al. The CDC Guide to Breast-feeding
Interventions. Atlanta: US DHHS,
CDC, 2005.
Acknowledgements
Terry Cline, Ph.D.
Commissioner of Health and Secretary of
Health and Human Services
Stephen W. Ronck, M.P.H.
Deputy Commissioner, Community and
Family Health Services, Oklahoma State
Department of Health
Suzanna Dooley, M.S., A.R.N.P.
Chief, Maternal and Child Health Service,
Oklahoma State Department of Health
Special assistance for this piece was
provided by: Nancy Bacon, MS, RD/LD;
Susan Harman, MPH (Oklahoma City
Area Inter-Tribal Health Board); Dana
Coles, MPH, CPH; Binitha Kunnel, MS;
Alicia M. Lincoln, MSW, MSPH; Paul
Patrick, MPH; and Lisa McKnight.
Funding for TOTS is provided by the
Maternal and Child Health Bureau,
Department of Health and Human
Services, MCH Title V Block Grant. The
TOTS Brief is issued by the Oklahoma
State Department of Health, as
authorized by Terry Cline, Ph.D.,
Commissioner of Health and Secretary of
Health and Human Services. Docutech
printed 1,200 copies in July 2011 at a
cost of $348. Copies were deposited
with the Publications Clearinghouse of
the Oklahoma Department of Libraries.
29.7
15.3
28.8
31.2
13.3
7.7
8.8
14.0
3.9
2.6 3.8 3.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
OKLAHOMA Native American Black White
Percent
Breastfeeding Duration Rates for Oklahoma's Toddlers
by Maternal Race, TOTS 2006-2009
6 months
or more
12 months
or more
18 months
or more

The Oklahoma Toddler
Survey (TOTS) is a two-year
follow-back survey to
the Oklahoma Pregnancy
Risk Assessment Monitor-ing
System (PRAMS) survey.
TOTS, developed in 1994,
provides a glimpse into the
health of Oklahoma’s tod-dler
population. Key topics
include health insurance,
child care, safety, tobacco
exposure, breastfeeding and
nutrition, illness and activity
limitations, injury, family
structure, and maternal and
paternal demographics.
Mothers with live infants
who respond to the PRAMS
survey are sent a TOTS
survey the month their
children turn 2-years-old.
TOTS is a mixed-mode sur-veillance
system. Two mail
surveys are sent in an
effort to gain participation
followed by telephone
surveillance for non-respondents.
The response
rate for 2006-2009 data
was 73.8% (n=5,221). Data
were weighted to repre-sent
the 2-year-old’s birth
cohort for those years.
For more information
please contact TOTS at
the Oklahoma State De-partment
of Health
(OSDH) at 405-271-6761
or TOTS@health.ok.gov.
Breastfeeding is a health
behavior with immediate
and long-term health
benefits for both the
mother and her infant.1
Advantages include
nutritional, immunologic,
developmental, psychologi-cal,
social, economic, and
environmental benefits.2
Maternal health benefits
include decreased post-partum
bleeding, decreased
risk of ovarian and breast
cancers, and an earlier
return to pre-pregnancy
weight. Child health
benefits include reduced
risks for common childhood
illnesses such as diarrhea,
respiratory tract infec-tions,
otitis media, and
urinary tract infections.
Most importantly, clinical
studies indicate breastfeed-ing
is an effective component
in the prevention of
childhood obesity.
Breastfeeding duration has
an inverse relationship to
pediatric overweight.3 The
Centers for Disease Control
and Prevention (CDC) esti-mates
that for every month a
child is breastfed, his or her
risk for childhood overweight
decreases by 4%, reaching a
plateau by nine months. Re-search
shows a 30% de-crease
in the odds for being
overweight for a child
breastfed for at least eight
full months when com-pared
to a child who was
never breastfed.3 The
American Academy of
Pediatrics (AAP) recom-mends
exclusive breast-feeding
for at least six
months.2
The breastfeeding goals
set forth in Healthy
People 2020 are to have
at least 60.6% of infants
breastfed for at least six
months, and have 34.1% of
infants breastfed until 12
months of age.
TOTS data from 2006-
2009 indicate that among
Oklahoma 2-year-olds only
29.7% (95% Confidence
Breastfeeding Duration Among Native Americans
July 2011
Volume 4, Issue 1
TOTS Brief
The Oklahoma Toddler Survey
In Oklahoma:
· Almost 30% of infants
were breastfed for at
least six months.
Thirteen percent were
breastfed for at least
12 months and 3.9%
breastfed for 18
months or more.
· Among Native Ameri-can
toddlers, 15.3% (CI
10.9, 21.0) were
breastfed at least six
months, the lowest
percentage of all races
for toddlers breastfed
or given breast milk for
at least six months.
· For Native American
mothers, non-smokers
were twice as likely as
smokers to breastfeed
for six months or more
(45% vs. 23%).
· Maternal education was
the most significant
predictor of breast-feeding
duration at six
months among Native
American mothers.
An EEO Employer
What is TOTS?
Only 7.7% of Native American mothers breastfed their babies until 12
months of age, far less than the 34.1% goal for Healthy People 2020.
Interval (CI) 27.8–31.7) were breastfed
for at least six months; and 13.3% (95% CI
11.9-14.8) were breastfed at least 12
months. Overall, Native American toddlers
were shown to have the lowest duration
rate at six months (15.3%, 95% CI 10.9-
21.0) compared to white toddlers (31.2%,
95% CI 29.0-33.5).
Among Native Americans, maternal
education was the only significant predictor
of breastfeeding duration at six months
when controlling for select maternal
demographics, behaviors, and characteris-tics.
Native American mothers who had
attained at least a high school education
were 14 times more likely to breastfeed
for six months or more when compared to
Native American mothers with less than a
high school education (data not shown).
The OSDH Maternal and Child Health
Service and the Oklahoma City Area
Inter-Tribal Health Board Tribal
Breastfeeding Duration, cont.
Epidemiology Center are working
together to improve breastfeeding
initiation and duration rates in Oklahoma.
Six evidence-based interventions to pro-mote
breastfeeding are: Maternity care
practices; support for breastfeeding in
the workplace; peer support; educating
mothers; professional support; and media
and social marketing. The effectiveness
of professional education and public
acceptance has yet to be established.4
References:
1. Rhodes KL, et. Al., American Indian Breast-feeding
Attitudes and Practices in Minnesota,
Maternal and Child Health Journal , 2008 Vol.
12, Supp. 1, 46-54.
2. Policy Statement. Pediatrics, Vol. 115,
No. 2 Feb 2005, pp. 496-506.
3. Harder T, Bergmann R, Kallischnigg G, Plage-mann
A. Duration of breastfeeding and risk
of overweight: a meta-analysis. Am J Epide-miol
2005; 162:397-403.
4. Shealy KR, et al. The CDC Guide to Breast-feeding
Interventions. Atlanta: US DHHS,
CDC, 2005.
Acknowledgements
Terry Cline, Ph.D.
Commissioner of Health and Secretary of
Health and Human Services
Stephen W. Ronck, M.P.H.
Deputy Commissioner, Community and
Family Health Services, Oklahoma State
Department of Health
Suzanna Dooley, M.S., A.R.N.P.
Chief, Maternal and Child Health Service,
Oklahoma State Department of Health
Special assistance for this piece was
provided by: Nancy Bacon, MS, RD/LD;
Susan Harman, MPH (Oklahoma City
Area Inter-Tribal Health Board); Dana
Coles, MPH, CPH; Binitha Kunnel, MS;
Alicia M. Lincoln, MSW, MSPH; Paul
Patrick, MPH; and Lisa McKnight.
Funding for TOTS is provided by the
Maternal and Child Health Bureau,
Department of Health and Human
Services, MCH Title V Block Grant. The
TOTS Brief is issued by the Oklahoma
State Department of Health, as
authorized by Terry Cline, Ph.D.,
Commissioner of Health and Secretary of
Health and Human Services. Docutech
printed 1,200 copies in July 2011 at a
cost of $348. Copies were deposited
with the Publications Clearinghouse of
the Oklahoma Department of Libraries.
29.7
15.3
28.8
31.2
13.3
7.7
8.8
14.0
3.9
2.6 3.8 3.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
OKLAHOMA Native American Black White
Percent
Breastfeeding Duration Rates for Oklahoma's Toddlers
by Maternal Race, TOTS 2006-2009
6 months
or more
12 months
or more
18 months
or more